FS Form 5735 Department of the Treasury | Bureau of the Fiscal Service July 2016
REQUEST FOR REASONABLE
Applicant/Employee Name: Date of Request:
Ofce, Location and Address:
Supervisor’s Name: Supervisor’s Phone Number:
Occupational Series and Grade:
Applicant/Employee Phone Number:
Briey describe the medical condition
Briey describe the specic accommodation being requested: (If additional space is needed, attach a separate sheet.)
If the requested accommodation is time sensitive, please explain:
Explain how the requested accommodation would assist you in: (1) performing the essential duties of your position,
(2) using the job application process, or (3) taking advantage of a benet or privilege offered by the Fiscal Service.
Requester’s Signature: Date:
In reviewing your request, it may be determined that medical documentation is needed to support your accommodation request.
If that is the case, you will be requested to provide limited medical information sufcient to support your request.
NOTICE UNDER THE PRIVACY ACT
The authority for collecting this information is The Rehabilitation Act of 1973 (29 U.S.C. § 701), as amended and Executive Order 13164. This information will be used
by the Equal Employment Opportunity and Diversity Ofce to process the request for a reasonable accommodation, and to report on the reasonable accommodation
program as mandated by federal law. The information on this form may be disclosed as generally permitted under the Privacy Act of 1974, as amended, 5 U.S.C. §
552a. Furnishing this information is voluntary; however, failure to furnish the requested information may delay or prevent the processing of the request.
Please Return to: Fiscal Service Disability Program Manager
200 Third Street, Room 301, Parkersburg, WV 26106
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